NUR 621 Healthcare Reimbursement Training 

Grand Canyon University NUR 621 Healthcare Reimbursement Training  – Step-By-Step Guide

This guide will demonstrate how to complete the Grand Canyon University NUR 621 Healthcare Reimbursement Training assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NUR 621 Healthcare Reimbursement Training                  

Whether one passes or fails an academic assignment such as the Grand Canyon University NUR 621 Healthcare Reimbursement Training depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NUR 621 Healthcare Reimbursement Training                  

The introduction for the Grand Canyon University NUR 621 Healthcare Reimbursement Training is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NUR 621 Healthcare Reimbursement Training                  

After the introduction, move into the main part of the NUR 621 Healthcare Reimbursement Training assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NUR 621 Healthcare Reimbursement Training                  

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NUR 621 Healthcare Reimbursement Training                  

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NUR 621 Healthcare Reimbursement Training 

The purpose of this training, which focuses on healthcare reimbursement, is to introduce new nurses to healthcare insurance, the reimbursement process, and how insurance companies finance healthcare services. This will help staff members develop the better work habits and attitudes that are required for higher levels of productivity. The specific learning goals for this training are to: Assist new employees and other organization stakeholders in learning and identifying the different types of health insurance, such as Medicare, Medicaid, and private insurance, and how each of the health insurance reimburses money to the healthcare organizations. To comprehend the role of healthcare insurance in the provision of healthcare services.

What is healthcare reimbursement?

Healthcare reimbursement can be defined as the money received by a hospital, diagnostic center, or other healthcare institution for providing a medical service. The most typical form of reimbursement is fee-for-service (FFS) (Selden, 2020). The cost of a patient’s medical treatment is often partially or completely covered by health insurance or a government payer. Usually, a patient is also accountable for some of the expenses. Patients without health insurance are responsible for paying the whole cost of their treatment to the hospital or other healthcare institution (Marta et al., 2021). Usually, these services are paid for after they are received. The patient or the insurance provider, whoever is responsible for paying the medical expenses, will get a bill from the provider.

Why is healthcare reimbursement necessary?

The significance of healthcare reimbursement lies in its role of guaranteeing remuneration for healthcare providers in exchange for the services they render, thereby enabling them to sustain the provision of healthcare services (Haglin et al., 2020). Selecting an insurance plan that provides adequate coverage for healthcare expenses is a crucial aspect of healthcare reimbursement for patients, as it serves to reduce the financial burden imposed on patients in terms of reimbursing healthcare costs (Malmivaara, 2020).

How Medicare Reimburse Healthcare Organizations

Medicare offers insurance coverage to a substantial number of individuals in the United States who are either aged 65 and above or those under 65 with specific enduring disabilities (Haglin et al., 2020). Medicare beneficiaries have the option to seek medical services at a diverse range of facilities, with hospitals being frequently utilized for emergency treatment, inpatient procedures, and extended hospitalization periods. Medicare benefits frequently encompass care provided at such facilities under the purview of Medicare Part A, with the reimbursement for these services from Medicare exhibiting variability. The process of billing is determined by the provider’s affiliation with Medicare and the mean expense associated with the provision of care for a particular diagnosis or procedure.

The Medicaid reimbursement systems exhibit variations across different states, although certain similarities can be identified. The most prevalent method of reimbursement in healthcare is fee-for-service (FFS) (Dehnavi et al., 2021). Under the Fee-For-Service (FFS) model, providers are remunerated with a predetermined payment in return for the services they render. Fee-for-service (FFS) rates are designed to remunerate medical practitioners exclusively for the healthcare services rendered to an individual. As a result, medical practitioners do not derive advantages from this commercial transaction as they interact with individuals who possess private health coverage.

How Private Insurance Reimburse Healthcare Organizations

Private insurance companies engage in individual negotiations with healthcare providers and hospitals to establish mutually agreed-upon reimbursement rates. Certain healthcare facilities and healthcare providers may decline to admit patients if their insurance coverage does not offer sufficient reimbursement unless the situation qualifies as an emergency (Haglin et al., 2020). The conventional procedure entails the consumer’s payment of an initial premium to a health insurance company, thereby enabling the individual to collectively distribute the “risk” with numerous other enrollees who are making comparable payments (Czech et al., 2020).

Differences Between Cost, Charge, and Payment

For individuals seeking medical treatment, the cost typically denotes the financial obligation they are required to personally cover for healthcare services. The cost of delivering a service varies significantly from the amount incurred by providers, such as healthcare organizations or clinicians (Haglin et al., 2020). Moreover, the issue becomes more intricate as the cost to the healthcare provider is frequently determined by incorporating expenses from various categories such as personnel and equipment, which may appear unrelated to the care provided to an individual patient (Himmelstein et al., 2020).

Differences Between Cost, Charge, and Payment

The clarity of the relationship between price fluctuations and costs-per-service calculation could be enhanced by categorizing costs into specific components, such as “patient check-in” and “collecting medical history”. While it is technically feasible, conducting such an analysis would be labor-intensive (Haglin et al., 2020). It would involve meticulously observing and quantifying the amount of time spent on each task for a given episode, referred to as “labor input.” Additionally, it would necessitate accounting for expenses related to space, non-consumable equipment, and administrative overhead on a minute-by-minute basis. A limited number of provider organizations demonstrate a willingness to invest such a level of effort.

Payment is a remittance issued by a party other than the recipient to compensate a service provider for rendered services (Abràmoff et al., 2022). There are various methods by which healthcare services can be financially compensated. These include a fee-for-service model, where a specific amount is charged for each service rendered, a per diem model, where a fixed daily rate is charged for hospital stays, a diagnosis-related groups (DRGs) model, where a predetermined amount is charged for each episode of hospitalization based on the diagnosis, and a capitation model, where a fixed amount is charged for each patient under the provider’s care.

Diagnostic Related Groups (DRGs)

Diagnostic Related Groups (DRGs) are employed as a means of categorizing patients who share comparable clinical conditions and treatment requirements. An instance can be observed in which a patient who has undergone a surgical procedure for a knee replacement would be classified within the Diagnosis-Related Group (DRG) 469 (Haglin et al., 2020). This particular DRG pertains to major joint replacement or reattachment of the lower extremity, specifically when accompanied by a Major Complication or Comorbidity (MCC). The determination of this Diagnosis-Related Group (DRG) incorporates an assessment of the patient’s medical condition, the intricacy of the procedure, and any potential complications or comorbidities that could impact the provision of healthcare to the patient.

Based on the patient’s diagnosis and the services given while they were a patient in the hospital, Medicare uses DRG to pay hospitals for inpatient stays (Bredenkamp et al., 2020). As a result, hospitals get a set payment for each patient depending on the DRG that was given to them. DRGs first appeared in the Medicare Prospective Payment System (PPS)  in 1982 (Abràmoff et al., 2022). The new system was designed to take the place of the old one, which reimbursed providers based on the real costs of delivering treatment. To assist decide the reimbursement a hospital will get for providing treatment to a patient, DRGs are a means to divide hospital inpatient cases into groups that are anticipated to have comparable expenses.

DRGs come in a variety of forms and are used in several contexts. One form is the Major Diagnostic Category (MDC) DRG, which, for financial reasons, compiles patients with comparable diagnoses and therapies (Abràmoff et al., 2022). The Surgical DRG is an additional kind that is used to classify patients according to the surgical treatments they undergo. Other DRGs include Transfer DRGs, which are used when a patient is moved to another hospital, and Pediatric DRGs, which are used for children. Some DRGs, like those for HIV/AIDS or mental health, are tailored specifically to those disorders. Healthcare practitioners and billing specialists must comprehend the various DRG classes to correctly classify and charge for services.

How Insurance Reimbursement Affects Private Pay Patients

Individuals lacking health insurance tend to incur lower out-of-pocket expenses for healthcare compared to those who possess health insurance, primarily due to their reduced utilization of services that are both less frequent and less expensive (Selden, 2020). Uninsured households bear a greater burden of their overall healthcare expenses through direct payments compared to insured households. Moreover, uninsured households are more prone to experiencing significant medical costs in their income levels. Adults without health insurance are at a decreased likelihood compared to adults with any form of health coverage to obtain preventive and screening services, as well as experiencing delays in receiving these services. 

Summary

The healthcare reimbursement systems in the United States encompass a combination of public and private third-party coverage (Dehnavi et al., 2021). These systems involve contributions from employers, individuals, and the government to cover the expenses associated with healthcare. Individuals and employers remunerate private insurance companies with premiums to defray healthcare expenses. Government coverage is available to specific populations at both the federal level, through programs such as Medicare, the Department of Defense, and the Bureau of Indian Affairs, and at the state level, through programs like Medicaid. Typically, these sub-populations encompass individuals who are classified as elderly (aged 65 and above), low-income, disabled, and veterans, among other categories. Private insurers have the potential to offer healthcare coverage to individuals who are beneficiaries of government insurance programs such as Medicare or Medicaid.

References

•Abràmoff, M. D., Roehrenbeck, C., Trujillo, S., Goldstein, J., Graves, A. S., Repka, M. X., & Silva III, E. “Zeke”. (2022). A reimbursement framework for artificial intelligence in healthcare. Npj Digital Medicine, 5(1). https://doi.org/10.1038/s41746-022-00621-w

•Bredenkamp, C., Bales, S., & Kristiina Kahur. (2020). Transition to diagnosis-related group (DRG) payments for health : lessons from case studies. World Bank Group.

•Czech, M., Baran-Kooiker, A., Atikeler, K., Demirtshyan, M., Gaitova, K., Holownia-Voloskova, M., Turcu-Stiolica, A., Kooiker, C., Piniazhko, O., Konstandyan, N., Zalis’ka, O., & Sykut-Cegielska, J. (2020). A Review of Rare Disease Policies and Orphan Drug Reimbursement Systems in 12 Eurasian Countries. Frontiers in Public Health, 7. https://doi.org/10.3389/fpubh.2019.00416

•Dehnavi, Z., Ayatollahi, H., Hemmat, M., & Abbasi, R. (2021). Upcoding Medicare: Is Healthcare Fraud And Abuse Increasing? Perspectives in Health Information Management, 18(4), 1f. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/

•Haglin, J. M., Eltorai, A. E. M., Richter, K. R., Jogerst, K., & Daniels, A. H. (2020). Medicare Reimbursement for General Surgery Procedures. Annals of Surgery, 271(1), 17–22. https://doi.org/10.1097/sla.0000000000003289

•Haglin, J. M., Richter, K. R., & Patel, N. P. (2020). Trends in Medicare reimbursement for neurosurgical procedures: 2000 to 2018. Journal of Neurosurgery, 132(2), 649–655. https://doi.org/10.3171/2018.8.jns181949

•Himmelstein, D. U., Campbell, T., & Woolhandler, S. (2020). Health Care Administrative Costs in the United States and Canada, 2017. Annals of Internal Medicine, 172(2), 134. https://doi.org/10.7326/m19-2818

•Malmivaara, A. (2020). Vision and strategy for healthcare: Competence is a necessity. Journal of Rehabilitation Medicine, 52(5), 0. https://doi.org/10.2340/16501977-2684

•Marta, G. N., Ramiah, D., Kaidar-Person, O., Kirby, A., Coles, C., Jagsi, R., Hijal, T., Sancho, G., Zissiadis, Y., Pignol, J.-P. ., Ho, A. Y., Cheng, S. H.-C. ., Offersen, B. V., Meattini, I., & Poortmans, P. (2021). The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report. Clinical Oncology, 33(5), 322–330. https://doi.org/10.1016/j.clon.2020.12.008

•Selden, T. M. (2020). Differences Between Public And Private Hospital Payment Rates Narrowed, 2012–16. Health Affairs, 39(1), 94–99. https://doi.org/10.1377/hlthaff.2019.00415

After learning about the difference between retrospective cost reimbursement and the prospective payment system, I have learned that nursing units for the most part can in fact generate a fair amount of revenue by being efficient in their care, preventing hospital acquired ailments, and caring for patients by addressing their illness prior to developing exacerbations, or delays in care. Hospitals do get reimbursed from insurances such as medicare and medicaid for care ranging from long-term and primary care, to preventative services (Leger, 2023). These reimbursements are made based on diagnosis-related groups (DRG)which “represent fixed amounts for each hospital stay,” and when the hospital spends less than the DRG estimated on patient care, it makes a profit and vice versa (Lambert, 2018).

 It is often the goal of nurse leaders on each unit to not only reduce any hospital related complications, but to care for the patients as efficiently as possible to reduce the amount of supplies and treatments needed for the patients, improve their care, and increase the chances of being reimbursed. Nurse leaders make it well known that if a patient has a hospital fall, the patient has a worse mortality rate, longer length of stay, and the hospital will lose money. By encouraging fall prevention, infection prevention, and other preventative measures, the hospital is ensuring patient safety while ensuring revenue is generated. This system not only encourages hospitals to better their care and shorten their hospital length of stay, but ensures that nursing units make a profit with each case.

Nurses are known to provide high quality care that patients trust. This quality care on top of higher patient satisfaction rates contributes to better revenue generated for the hospital. With the help of nurse leaders ensuring the care in their unit is efficient and prevents any complications, patients could be more satisfied with their care, and insurance companies reimburse the organizations fully. These reimbursements prove that nursing units are capable of making revenue for the organization that may not be otherwise expected. 

References

Lambert, D. (2018). Healthcare 101: How Healthcare Reimbursement Works? Continuum. https://www.carecloud.com/continuum/how-healthcare-reimbursement-works/#:~:text=Hospitals%20are%20paid%20based%20on

Leger, J. M. (2023). Financial management for nurse managers: Merging the heart with the dollar (5th ed.). Jones & Bartlett Learning.